HomeMy Public PortalAbout9636 VAL ST_Sewer__ ::62333 APPLICATION FOR PERMIT 1
DIVISION OF WELDING AND SAMY SEWER-SEWAGE DISPOSAL
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WM.J FOX. COUNTY ENGIN. ADDRESS
CAHSATTD GRIMM,lil ' oP ouILol" LOCALITY
FOR APPLICANT TO FILL IN NEARESTRISS
LEGAL
DESCRIPTION LOT NO • OWNER
BLOCK TRACT MAIL
ADDRES //
SIZE OF LOT NOW ON LOOS ClTE D u 33
USE OF
BUILDINGS DISTRICT N GROUP MAP
BK PG
CONTRACTOR j
AODRE CONNECTION DATA
7 r
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TEL STATION / DEPTH
@STATE MANHOLE REFERENCEZ�FM701011"REGISTRATION NO d 6 ❑ COUNTY LOWER
No DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF C
Y ONNECTI 1 LENGTH FROM
PUBLIC SEWER j 3 EO CURS P L M L TO P L r
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1 00 _
CONNECT ADDITIONAL BLDG OR / F C NO
' WORK TO HOUSE SEWER 1 00 CO IMP NO JOB NO
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO ROAD PERMIT NO
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM too PERMIT NO
SEPTIC TANK. SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 200 INDUSTRIAL
CESSPOOL DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 200 a CHARGES
i
pEHI�I,i CONNECTION CHARGE FEE
OWNMS S 1 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
1 HAVE TRACTORTO DATE CONNECT THEACTED ABOVEWITH THE DESCR DESCRIBED EXIISTING DWELLEIN N ED ONG APPROVALS DATE INSPECTOR SSIGNATURE
TO THE PUBLIC SEWER
SIGNED THI ' OF I
NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS E BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PITISI
AMD/OR DNAINF12LD
1 HEREBY ACR OWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS SEWAGEREPAIR SEWER OR
SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AN PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY L09 ANGELES CO �y�y�111 ATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT HE L OW TER OF f OVfi ABANDON ROUSE SEWER
DESCRIBED REFI L H Bw
BACKFILL SE
C TARES f�l /
" BEEP PITS CESSP00 `u
LIGNATUR6
OF PERMITTEE
WILLIAM J.FOX.C.6umyy ENommm VALIDATION R A WOOD. CNIEa PLED. INSPECTOR
X07 ^ CO.-" 51P l 3 4 4 .5 0 ID
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